Every finding on record at Crandall Nursing Home

Based on resident record reviews, observations, staff interviews and facility policy review, the facility failed to maintain dignity while dining. This affected three residents (#85, #88, #93) of three reviewed for dignity. The facility census was 112.Findings include:1. Review of the medical record for Resident #85 revealed he was admitted on [DATE] with diagnoses that included dysphagia, major depressive disorder, and presence of cardiac pacemaker. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 was dependent on staff for activities of daily living (ADL) and had a Brief Interview for Metal Status (BIMS) score of seven indicating severe cognitive impairment.2. Review of the medical record for Resident #88 revealed he was admitted to the facility on [DATE] with diagnoses that included orthopedic aftercare, fracture of the right femur, and nocturia. Review of the MDS assessment dated [DATE] revealed Resident #88 was dependent on staff for ADL and had a BIMS score of four, indicating severe cognitive impairment.3. Review of the medical record for Resident #93 revealed he was admitted to the facility 0n 12/05/25 with diagnoses that included paroxysmal atrial fibrillation, anorexia nervosa, and hypertension. Review of the MDS assessment dated [DATE] revealed Resident #93 was dependent on staff for ADL and had a BIMS score of six, indicating severe cognitive impairment.Observation on 03/23/26 at 11:50 A.M. revealed Residents #85, #88, and #93 seated together at a table in the main common area on the second floor of the facility, central to the nursing station. Observation revealed Resident #88 with a lunch tray placed in front of him eating the lunch meal that consisted of a bacon, lettuce and tomato sandwich and macaroni salad. Resident #93 was seated directly to the right of Resident #88, and Resident #85 was seated across the table in front of Resident #88. Both Residents #85 and #93 did not have a lunch tray present.Interview and observation on 03/23/26 at 12:02 P.M. with Certified Nurse Assistant (CNA) #300 revealed Residents #85, #88, and #95 were seated at the table for their lunch meal. CNA #300 revealed Resident #88's tray arrived before Residents #85 and #93 lunch trays and would be arriving with the next meal cart. Observation revealed CNA #300 continued to provide lunch trays to random residents eating in their rooms. CNA #300 verified the above findings at the time of the interview.Observation on 03/23/26 at 12:19 P.M., approximately 17 minutes later, revealed a second meal cart arrived to the second-floor main common area. Observation revealed random staff providing lunch meal trays to random residents eating in their rooms. Residents #85 and #93's lunch meal tray was not on the second meal cart.Interview on 03/23/26 at 12:27 P.M. with Licensed Practical Nurse (LPN) #302 revealed Residents #85, #88, and #93 were seated at the table for their lunch meals. LPN #302 revealed Residents #85 and #93's lunch trays had not arrived. LPN #302 stated meal trays take a long time to be delivered. LPN #302 verified the above findings at the time of the interview.Observation on 03/23/26 at 12:28 P.M., approximately 40 minutes after Resident #88's lunch meal tray was delivered, revealed a third meal cart arrived to the second-floor main common area. Observation revealed Resident #88's lunch meal was completed, and he exited the table. Observation revealed Resident #85's lunch tray arrived and was provided to him. Resident #93's lunch meal tray was not provided at that time.Observation on 03/23/26 at 12:32 P.M., approximately two minutes later, Resident #95's lunch meal tray arrived and was provided to him.Interview on 03/23/26 at 12:34 P.M. with CNA #300 verified the above findings at the time of the observation.Interview on 03/24/26 at 3:10 P.M. with the Administrator verified Residents #85, #88, and #93 did not experience dignity while dining due to lunch meals trays not being delivered at the same time.Review of the facility document titled Dining Choices policy, updated 07/19/25, revealed the facility had a policy in place that residents would receive their meals along with other residents during dining services. Review of the document revealed the facility did not implement the policy.

Based on record review, observation and interview, the facility failed to provide ordered mobility interventions for Resident #10. This affected one resident (#10) of one resident reviewed for range of motion. The facility census was 112.Findings include:Record review of Resident #10 revealed he was admitted [DATE] and had diagnoses including cerebral infarction, Parkinson's disease, neurocognitive disorder with [NAME] bodies, and dementia. Review of his orders revealed one dated 06/20/24 for the resident to wear a foam sleeve to the left thumb as tolerated, to be removed for skin checks and hygiene. The order was both discontinued and reordered on 03/20/26, with the clarification that it was to be done three times per day. Review of his range of motion assessment dated [DATE] revealed both hands were contracted. Review of his administration records and progress notes revealed no documentation of the foam sleeve being applied or attempted on any date. Review of his point of care charting revealed six instances from 03/20/26 to 03/23/26 where the foam sleeve was documented as reviewed.Observations on 03/23/26 at 8:59 A.M. and 3:08 P.M. revealed Resident #10 did not have any sleeve on his left thumb. His left hand was contracted into a fist with the thumb pressed between the fore and middle fingers. A foam dressing rested on top of the middle finger between it and the thumb. He was not interviewable.Interview with Registered Nurse (RN) #306 on 03/23/26 at 3:21 P.M. revealed Resident #10 was uncomfortable when too much was placed between his fingers and needed the foam dressing there to treat a moisture injury. The goal of the ordered cloth sleeve was to prevent the thumb from pressing down on the middle finger, which was accomplished with the foam dressing, so the facility was leaving it off.Interview with the Director of Nursing (DON) and RN #306 on 03/24/26 at 10:12 A.M. confirmed Resident #10's chart had no specific documentation of the ordered cloth sleeve to the thumb being applied, that it was not present during surveyor observations, and that there were no notes evidencing a rationale for it being not applied. Review of computer charting both before and after the facility's computer changeover on 02/23/26 revealed no record of the cloth sleeve being applied. RN #306 said the documentation of it being reviewed from 03/20/26 to 03/23/26 did not necessarily mean the sleeve was applied. The DON indicated at this time the sleeve application fell under the treatment record under all services rendered documented done three times per day; however, the surveyor confirmed with him at this time that record made no specific mention of the application or tolerance of the sleeve.

Based on resident record review, observations, resident interview, staff interviews, and facility policy review, the facility failed to clearly distinguish, document and implement fall interventions to decrease the risk of falls. This affected one resident (#33) of one reviewed for falls. The facility census was 112.Findings include:Review of the medical record for Resident #33 revealed she was readmitted to the facility on [DATE], after a fall with a major injury, with diagnoses that included Alzheimer's disease, fracture of the right clavicle, and multiple fractures of left side ribs. Resident #33 was initially admitted on [DATE] with diagnoses of difficulty in walking, weakness, and fracture of radial styloid.Review of the care plan dated 04/28/25 revealed Resident #33 was at risk for falls related to a history of falls and fall related fractures with interventions that included keeping call light within reach and/or call light at hip level when in bed and within reach when in chair.Review of the progress note dated 11/30/25 at 5:14 P.M. revealed Resident #33 had a fall while ambulating, lost her balance, fell, landed on her right side and caught herself with her left wrist that resulted in an x-ray.Review of the fall investigation dated 11/30/25 revealed Resident #33 had a fall that resulted in no interventions due to isolated incident.Review of the progress note dated 12/01/25 at 10:21 A.M. revealed Resident #33 x-ray results returned a diagnosis of osteopenia. Degenerative changes to carpometacarpal joints, age indeterminate fracture in the left radial styloid, and officiation of the radiocarpal and ulnocarpal joint space with orders for ace wrap and ortho consult.Review of the progress note dated 12/05/25 at 12:28 P.M. revealed Resident #33 fall was an isolated incident with interventions of supervision with ambulation.Review of the progress note dated 12/15/25 at 7:03 A.M. revealed Resident #33 informed staff she fell in the bathroom in the morning, hit her left side with noted bruise to the left back side of rib.Review of the progress note dated 12/15/25 at 8:33 A.M. revealed Resident #33 had a new fall intervention to implement the falling star policy and protocol.Review of the fall investigation dated 12/15/25 revealed Resident #33 had a fall that resulted in a falling star protocol intervention.Review of the progress note dated 12/16/25 at 9:42 A.M. revealed Resident #33 received in-house x-ray of the left ribs.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. Resident #33 required supervision and/or touching assistance for walking and sit-to-stand and/or stand-to-sit transfers.Review of the fall risk assessment dated [DATE] revealed Resident #33 required the use of a walker, wheelchair, and/or cane.Review of the physician orders dated 03/18/26 revealed orders to implement the falling star protocol, call light at hip while in bed, and supervision for ambulation and transfers.Review of the point of care history related to ADL revealed fluctuating interventions of supervision or touching assistance to independent for functional abilities.Observation on 03/23/26 at 9:03 A.M. revealed Resident #33 was seated in her room on the edge of her bed with the door closed. Resident #33's call light was located approximately six feet away wrapped around a lamp shade. Resident #33's call light was not in reach. Observation revealed no ambulatory devices to assist Resident #33 with ambulation. Resident #33 appeared confused and continually performed sit-to-stand transfers.Observation on 03/23/26 at 9:05 A.M. revealed no staff monitoring Resident #33.Interview and observation on 03/23/26 at 10:50 A.M. with Certified Nursing Assistant (CNA) #304 revealed Resident #33 was confused, was a fall risk and continually stood up and down and walked back and forth. CNA #304 revealed she was aware Resident #33 had a fall that resulted in fractured ribs, but she did not recall when she had the fall. CNA #304 revealed Resident #33 had multiple fall interventions that included keeping her call light within reach and implementing the falling star protocol, which consisted of frequent monitoring. CNA #304 revealed Resident #33 was unable to be monitored with her door closed; however, was independent with ADL. CNA #304 entered Resident #33's room and verified Resident #33's call light being out of reach and lack of monitoring.Interview on 03/24/26 at 3:10 P.M. with the Administrator confirmed Resident #33 had a fall with major injury that resulted in fractured ribs and required clear fall interventions.Review of Resident #33 medical record, who admitted to the facility as a result of a fall with fracture, revealed conflicting information in varying parts of her medical record and did not reflect or designate a clear fall intervention to prevent future falls and allow staff to maintain a safe environment.Review of the facility fall document protocols documents titled Falling Star Protocol Point System Policy and Procedure and Fall Prevention Policy and Procedure, updated and revised 07/22/25, revealed the facility had a policy in place to provide the highest quality of care in the safest environment after a fall occurs by implementing an assessment to determine what protocol to initiate. Review of the policies revealed the facility had two protocols based on the results of a resident's assessment post fall. Review of the policies revealed after a fall occurs interventions would be reviewed, discussed, documented and put into place as indicated. Review of the document revealed the facility did not implement the policy.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of hospital records, review of a self-reported incident (SRI), and interview, the facility failed to ensure Resident #54 was safely transferred in a mechanical lift to prevent fall with major injury. Actual harm occurred on 12/15/25 at approximately 1:10 P.M. when Resident #54, who was cognitively impaired and dependent on staff to transfer, sustained a fall from a mechanical lift device during a staff assisted transfer that resulted in a subarachnoid hemorrhage (brain bleed), which the hospital physician noted had the potential to be a serious and life-threatening condition. The facility identified the fall occurred as a result of human error as staff did not ensure the loop of the sling was properly secured prior to lifting Resident #54 out of her chair during the transfer. This affected one resident (#54) out of five records reviewed for falls and transfer assistance. The facility census was 110. Findings include: Review of the medical record for Resident #54 revealed an admission date of 10/23/18 with diagnoses including history of falling, Alzheimer's disease, dementia, hypertension, anxiety, major depressive disorder, age-related physical debility, and abnormal posture. Review of the physician's orders for Resident #54 revealed an order dated 11/21/24 for a mechanical lift for all transfers. Review of the activities of daily living (ADL) care plan revised 12/15/25 revealed Resident #54 demonstrated an impaired ability to complete activity of daily living (ADL) activity without assistance due to Alzheimer's dementia, glaucoma, and osteoarthritis. Interventions included, but were not limited to, mechanical lift for all transfers (revised 12/15/25). Review of a fall plan of care revised 12/15/25 revealed Resident #54 was at-risk for falls due to Alzheimer's dementia, overall debility, confusion, impaired safety awareness, impaired mobility, and poor vision. Interventions included, but were not limited to, maintaining a safe environment (revised 12/15/25), monitor, anticipate, and intervene regarding possible factors that may facilitate a fall (revised 12/15/25), notify physician of all falls and injuries (revised 12/15/25), and complete a fall risk assessment on admission, quarterly, and as needed (revised 12/15/25). Review of the facility's incident report dated 12/15/25 at 1:10 P.M. revealed Resident #54 was lying on the floor on her back with her legs and left upper body over the bottom of the mechanical lift device. Resident #54 had visible blood from an open area to the left side of the forehead with an accompanying lump measuring approximately five centimeters (cm) in circumference. The lift device was removed from underneath Resident #54, the wound to the head was cleaned and dressed, and Resident #54 was assisted to bed by three staff (with no indication as to how this transfer from the floor to the bed occurred). Resident #54 also had deep purple coloration to right lateral pointer finger (second digit). Resident #54 was not able to verbalize whether she was in pain but displayed indicators of pain while on the floor. This incident report failed to mention that Resident #54 fell from a mechanical lift device during a staff assisted transfer. Review of the nurse's note dated 12/15/25 at 3:56 P.M. revealed it was an exact replica of the nurse's summary contained in the incident report dated 12/15/25 at 1:10 P.M. Review of an incident witness statement dated 12/15/25, written by Certified Nursing Assistant (CNA) #500 revealed (during the transfer of Resident #54) the left bottom strap was not secured to the hook and Resident #54 fell to the floor before they could grab her. Review of incident witness statement dated 12/15/25, written by Certified Nursing Assistant (CNA) #501, revealed as they lifted Resident #54 into the air (to transfer), the strap came unclipped and Resident #54 went forward onto the floor. Review of hospital emergency room documentation dated 12/15/25 revealed Resident #54 arrived to the emergency room on [DATE] at 1:59 P.M. due to falling from a mechanical lift device at a nursing home. The emergency department history of present illness note indicated the mechanical lift was at the highest setting when Resident #54's fall occurred. Resident #54 received a computed tomography (CT) scan of the head while at the emergency room on [DATE] and the results indicated a subarachnoid hemorrhage (brain bleed). The hospital physician documented that this injury had the potential to be a serious and life-threatening condition. Resident #54's family elected not to treat Resident #54 in the hospital and the resident was discharged back to the facility on [DATE]. Review of a facility investigation of self-reported incident (SRI) tracking number 268640, created on 12/15/25 at 2:44 P.M., revealed Resident #54 fell from a mechanical lift during a staff assisted transfer. During the transfer, the left bottom loop of the sling came out of the hook on the mechanical lift, resulting in Resident #54 falling to the floor and hitting her head. Resident #54 was sent to the emergency department, where she was diagnosed with a facial laceration to the left side of the head and a brain bleed. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was rarely or never understood and had severely impaired cognitive skills for daily decision making. The assessment revealed Resident #54 was dependent (on staff) for chair/bed-to-chair transfers and had experienced one fall with major injury since the previous assessment. On 01/12/26 at 9:01 A.M., an interview with the Administrator and Assistant Director of Nursing (ADON) #498 revealed the incident that occurred with Resident #54 (on 12/15/25) was just an unfortunate accident. On 01/12/26 at 12:07 P.M., Resident #54 was observed sitting in a wheelchair in the dining room. Resident #54 was not interviewable. On 01/12/26 at 12:13 P.M., an interview with CNA #500 confirmed Resident #54 fell (on 12/15/25) from the mechanical lift during a staff assisted transfer. CNA #500 stated she and another CNA operated the mechanical lift to transfer Resident #54 from a chair to bed. CNA #500 said after they lifted Resident #54 out of the chair, they went to remove the chair from underneath her and CNA #500 noticed the loop of the sling had come off the hook on the lift device. CNA #500 said before they had time to react, Resident #54 face planted on the floor. CNA #500 further stated after the fall, Resident #54 was assisted back to bed by staff members lifting her off the floor without using a mechanical lift device. CNA #500 said the loop of the sling was not properly secured prior to lifting Resident #54 out of her chair. On 01/12/26 at 12:57 P.M., an interview with CNA #501 confirmed Resident #54 fell to the floor (on 12/15/25) and hit her head while staff were performing a transfer with a mechanical lift. CNA #501 stated they lifted Resident #54 up into the air and the lift sling came unhooked from the clip on the mechanical lift. Resident #54 hit her head and had a cut on her head. On 01/12/26 at 1:29 P.M., an interview with Registered Nurse (RN) #504 verified on 12/15/25 Resident #54 was on the floor at the time of her assessment and she had a laceration to the head, which was cleaned and dressed. On 01/12/26 at 1:35 P.M., an interview with Licensed Practical Nurse (LPN) #503 revealed she was passing medications at the time of Resident #54's fall on 12/15/25 and was notified by a manager of the fall that occurred while the resident was being transferred. Resident #54 was assessed and displayed facial grimacing at the time of the fall. However, Resident #54 was non-verbal and unable to verbalize pain. On 01/12/26 at 2:50 P.M., an interview with the Administrator revealed Resident #54's fall on 12/15/25 was an accident due to human error and not any sort of mechanical issue with the lift device. On 01/12/26 at 3:08 P.M., an interview with the Administrator verified Resident #54 had a brain bleed as a result of the fall from the mechanical lift that occurred on 12/15/25. The Administrator stated she did not think the transfer sling came unhooked from the mechanical lift, further clarifying that she thought CNA #501 did not ensure the sling was hooked securely before beginning the transfer. The Administrator said CNA #501 was talking and possibly distracted during the transfer, stating again that Resident #54's fall was an accident due to human error. On 01/12/26 at 4:34 P.M., an interview with the Director of Nursing (DON) revealed Resident #54's fall on 12/15/25 was caused by CNA #501 not double checking the loop was hooked onto the lift device before starting the transfer. Review of the facility's policy titled Procedure for Invacare Lift, dated 07/23/24, revealed two staff were required to operate the lift device and staff were to ensure the sling was hooked to the lift with the hooks facing the outside of the sling or away from the resident. The policy further stated it was the responsibility of the nursing aide to monitor the slings for rips, holes, fraying, or any other concerns with every use. Review of the facility's policy titled Invacare Lift Operating Instructions Policy and Procedure, dated 07/23/24, revealed the lifts were used to aide in the transfer of a resident who was not able to bear weight and a physician's order was required. Review of the facility's policy titled Fall Prevention Policy and Procedure, dated 07/22/24, revealed if a fall occurs, an incident report must be completed by the nurse, the physician and family would be notified in a timely manner, the incident would be discussed during morning report the following day, and interventions would be put in place as indicated. If the recommended intervention involves addressing an employees work performance, this will be referred to the staff development nurse for education or to the ADON for discipline as needed. The deficiency was corrected on 12/17/25 when the facility implemented the following corrective actions: On 12/15/25, Resident #54's physician was notified of the incident and new orders were given to transfer the resident to the hospital.On 12/15/25 by 1:59 P.M., Resident #54 was transferred to the emergency room for further evaluation and treatment.On 12/15/25, the mechanical lift device and transfer sling used at the time of the incident with Resident #54 were inspected by the facility's Maintenance Director and Assistant Director of Nursing for functionality with no concerns identified.On 12/15/25, the Administrator sent a mass text message to 62 Certified Nursing Assistants (CNAs), 29 Licensed Practical Nurses (LPNs), and 17 Registered Nurses (RNs) educating them on the need for two people for mechanical lift transfers and the need to monitor the resident and the equipment throughout the transfer process.On 12/15/25, Staff Educator #499 (who was also a LPN) educated 45 CNAs (out of 60 CNAs total) on the protocol for mechanical lift transfers and required a return demonstration to indicate understanding. The remaining 15 CNAs were educated by phone, have not worked in the facility since the incident, and would be required to perform a return demonstration upon arrival for their next scheduled shift at the facility.On 12/15/25 and 12/16/25, all mechanical lift devices and transfer slings throughout the facility were inspected by the facility's Maintenance Director and Assistant Director of Nursing (ADON) #498 for functionality and disposed of any slings with visible wear and tear. All mechanical lifts were functioning properly.On 12/17/25, Staff Educator #499 educated 27 LPNs (out of 30 LPNs total) and 12 RNs (out of 15 RNs total) on the protocol for mechanical lift transfers and required a return demonstration to indicate understanding. Two of the remaining three LPNs and two of the remaining three RNs were educated by phone, have not worked in the facility since the incident, and will be required to perform a return demonstration upon arrival for their next scheduled shift at the facility. The other one LPN and one RN were on medical leave and will receive education upon returning to work.On 12/17/25, the Administrator ordered 15 new transfer slings in varying sizes for the mechanical lift devices.The facility added this incident and staff education to Quality Assurance and Performance Improvement (QAPI) for continued monitoring.Mechanical lifts would continue to be routinely inspected for functionality every six months. This deficiency represents non-compliance investigated under Complaint Number 2712739.

Based on observation, staff interview, medical record review, review of safety data sheets (SDS), and review of facility policy, the facility failed to ensure personal care items, which could cause harm if consumed, were out of reach of residents who were cognitively impaired and residing in the facility's memory care unit. This affected five residents (#6, #7, #49, #58, and #90) and had the potential to affect 19 residents who the facility identified who have cognitive impairment and were independently mobile. The facility identified one resident (#82) who resided on the memory care unit as being immobile. The facility census was 112. Findings include: 1. Review of Resident #49's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia and Alzheimer's disease, and fatigue. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 12/19/24, revealed Resident #49 was rarely/never understood and required partial/moderate assistance to walk ten feet. Observation of Resident #49's room located in the memory care unit on 03/17/25 at 8:28 A.M. revealed on the windowsill in Resident #49's room there was one 8.8 ounce metal spray can of air freshener with a keep out of reach of children noted on the label. On the bedside table, there was one 8.8 ounce metal spray can of air freshener with a keep out of reach of children noted on the label. In the bathroom on the open shelving next to the toilet, there was one 4.5 ounce spray can of air freshener with a keep out of reach of children and pets noted on the label, one 16 ounce plastic spray bottle of 70 percent isopropyl alcohol with keep out of reach of children, one 32 ounce plastic bottle of 91% isopropyl alcohol with a keep out of reach of children and pets noted on the label, and one 10 fluid ounce plastic bottle of nail polish remover. Interview on 03/17/25 at 8:30 A.M. with Memory Care Director #859 confirmed the areas of concern and stated chemicals should not be visible and kept out of reach of the residents on the memory care unit. She stated there was a locked drawer in the bedside table where care products should be kept. Review of the SDS, revised 07/06/15, for Isopropyl Alcohol 70 percent, indicated the product with repeated or prolonged exposure could cause irritation to skin, irritation to eyes upon contact, respiratory irritation upon inhalation, and may be harmful if ingested. If the product was swallowed, the SDS sheet indicated the physician or poison control should be contacted for current information. The SDS for Isopropyl for Alcohol 90 percent, undated, indicated the product can affect the central nervous system, and there were indications that short-term damage could occur in the gastrointestinal system, liver, kidney, and the cardiovascular system. This product was to be kept out of reach of children . The SDS for air freshener, revised 02/24/25, indicated if the product was ingested, the SDS sheet indicated one to two glasses of water should be drunk and vomiting should not be induced. Medical attention should be sought immediately if symptoms occur, and the product should be kept out of reach of children. Review of the SDS for Nail Polish Remover, dated 08/24/16, indicated prolonged or repeated contact could dry skin and cause irritation. Exposure to the product could increase toxic effects, and inhalation could cause central nervous system effects. The SDS indicated when the product was inhaled vomiting should not be induced, and the physician should be consulted. For skin contact, the skin must be rinsed and monitored for irritation, and the product should be kept out of reach of children. 2. Review of Resident #58's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment, dated 01/26/25, revealed Resident #58 exhibited severe cognitive impairment and required supervision or touching assistance to walk ten feet. Observation of Resident #58's room located in the memory care unit on 03/17/25 at 7:49 A.M. revealed on the open shelving next to the toilet in the bathroom revealed, there was one air refresher 8.3 ounce metal can with keep out of reach of children and pets noted on the label, one 188 milliliter (ml) bottle of Brand #1 Aftershave Conditioner Fresh Scent with keep out of reach of children., two three fluid ounce bottle of Brand #2 After Shave Skin Conditioner Fresh Scent with a keep out of reach on the label, one 3.5 ounce of bottle of All Day Fresh Body Spray Cool Blast with keep out of reach of children. Interview on 03/17/25 at 8:32 A.M. with Memory Care Director #859 confirmed the areas of concern and stated chemicals should not be visible and kept out of reach of the residents on the memory care unit. She stated there was a locked drawer in the bedside table where care products should be kept. Review of the SDS for air refresher dated 08/01/18, indicated this product was to be kept away from children and would cause skin irritation. The SDS for Brand #1 Aftershave, revised date of 03/27/15, indicated the product was extremely flammable, would cause mild skin irritation, and was to be kept out of reach of children. The SDS for Power Stick Body Spray, dated 10/11/23, indicated the product could cause acute toxicity if not used as indicated. This product could cause mild skin irritation, and the physician should be contacted if irritation persisted. The SDS for Brand #2 After Shave Lotion dated 04/29/15 indicated this product contained hazardous substances and should not be swallowed. If ingested, a physician should be consulted. 3. Review of Resident #90's medical record revealed the resident was admitted on [DATE] with diagnoses including Alzheimer's disease and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/07/25, revealed Resident #90 exhibited severe cognitive impairment, required supervision or touching assistance to walk ten feet, and wandered one to three days during the assessment reference period. Observation of Resident #90's room located in memory care unit on 03/17/25 at 7:57 A.M. revealed on the open shelving in the bathroom sitting next to the toilet was one 8.8 fluid ounce plastic bottle of Beach fragrance mist with a keep out of reach of children noted on the label and one plastic two fluid ounce plastic bottle of Everlasting Love body mist with keep out of reach of children noted on the label. Interview on 03/17/25 at 8:33 A.M. with Memory Care Director #859 confirmed the areas of concern and stated chemicals should not be visible and kept out of reach of the residents on the memory care unit. She stated there was a locked drawer in the bedside table where care products should be kept. Review of the SDS for fragrance spray, dated 09/10/24, indicated the product could cause serious eye irritation and mild skin irritation. 4. Review of Resident #6's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia and Alzheimer's disease. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was rarely/never understood and required supervision or touching assistance to walk ten feet. Observation of Resident #6's room located in the memory care unit on 03/17/25 at 7:59 A.M. revealed on the open shelving in the bathroom next to the toilet was one seven fluid ounce plastic bottle of Vanilla Scent Body Mist with keep out of reach of children noted on the label and one two fluid ounce plastic bottle of Gingerbread Latte Fragrance mist with keep out of reach of children noted on the label. Interview on 03/17/25 at 8:34 A.M. with Memory Care Director #859 confirmed the areas of concern and stated chemicals should not be visible and kept out of reach of the residents on the memory care unit. She stated there was a locked drawer in the bedside table where care products should be kept. Review of SDS for fragrance spray dated 09/10/24 indicated the product could cause serious eye irritation and mild skin irritation. 5. Review of Resident #7's medical record revealed the resident was admitted on [DATE] with diagnoses including vascular dementia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 12/03/24, revealed Resident #7 exhibited severe cognitive impairment and required supervision with transfers and can walk with supervision. Observation of Resident #7's room located in the memory care unit on 03/17/25 at 7:54 A.M. revealed on the open shelving in the bathroom next to the toilet was one seven fluid ounce plastic bottle of body mist with a keep out of reach of children noted on the label and one two fluid ounce Gingerbread Latte fragrance mist with keep out of reach of children noted on the label. Interview on 03/17/25 at 8:35 A.M. with Memory Care Director #859 confirmed the areas of concern and stated chemicals should not be visible and kept out of reach of the residents on the memory care unit. She stated there was a locked drawer in the bedside table where care products should be kept. Review of the SDS for fragrance spray dated 09/10/24 indicated the product could cause serious eye irritation and mild skin irritation. Review of the facility policy titled Safety and Environmental Policy, updated 05/14/24, revealed the director of the unit would perform environmental rounds daily, which included inspecting all residents' rooms and bathrooms. If personal care products were deemed a safety concern for the resident, it would be discussed with family, and all personal care items would be removed from resident bathrooms. The director would provide ongoing education to staff and family members regarding unsafe items or situations found on the unit.

Based on medical record review, review of facility policy, and staff interview, the facility failed to ensure residents had accurate advance directive orders in place throughout their medical record and implement the facilities advance directive policy. This affected two (Residents #4 and #109) of 33 residents reviewed for advance directives. The facility census was 112. Findings include: 1. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure and fracture of the fibula. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 was cognitively intact. Review of the physician's orders for Resident #4 revealed an order dated 02/06/25 for a Do Not Resuscitate Comfort Care Arrest (DNRCCA) (meaning invasive or extreme life-supporting measures were allowed under any circumstance except for cardiac or respiratory arrest. In the event of cardiac or respiratory arrest only comfort measures would be initiated) code status. Review of the electronic chart for Resident #4 revealed a signed DNRCCA code status dated 02/06/25. Review of the hard medical chart for Resident #4 revealed a signed Do Not Resuscitate Comfort Care (DNRCC) code status (meaning only comfort measures would be initiated in the event of a medical emergency) dated 05/16/03. An interview on 03/18/25 at 9:06 A.M. with [NAME] Clerk #804 verified Resident #4's hard medical record had a signed advance directive for DNRCC, and the electronic chart had a signed DNRCCA code status. 46195 2. Review of medical record for Resident #109 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease and type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #109 was moderately impaired cognitively. Review of DNR (Do Not Resuscitate) Comfort Care document, signed and dated 12/11/24 by a nurse practitioner, revealed Resident #109's code status was a DNR Comfort Care-Arrest (DNRCCA), which meant the provider would treat the resident as any other without a DNR order until the point of cardiac arrest, at which point all other interventions would cease and the DNR Comfort Care protocol would be implemented. Review of Resident #109's physician orders revealed there was no order indicating Resident #109's code status was a DNRCCA. Interview on 03/18/25 at 3:16 PM with Registered Nurse # 814 confirmed Resident #109 didn't have a physician order in the medical record indicating Resident #109 was a DNRCCA. She stated the facility audited charts monthly to ensure the signed DNR form matched the physician order in the medical record and could not give a reason why Resident #109 didn't have a physician order for DNRCCA order in place. Review of facilities policy titled DNR Status Policy and Procedure, updated 07/19/24, revealed every resident should have clearly stated on their chart if they wish to be a DNRCC or DNRCCA, a physician's order, and a DNR form completed and signed by the provider.

Based on record review, review of facility policy, and resident and staff interview, the facility failed to ensure the residents had activities to meet their needs, especially on the weekends and evenings. This affected two (Residents #20 and #51) of two residents reviewed for activities. The facility census was 112. Findings include: 1. Review of Resident #20's medical record revealed the resident was admitted [DATE] with diagnoses including legal blindness, anxiety disorder and essential hypertension. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 exhibited intact cognition. Review of the activity care plan dated 02/03/25 revealed Resident #20 was at risk for social isolation and low activity participation related to blindness and periods of confusion. Interventions dated 02/03/25 included interviewing the resident about past roles, monitor for activity needs, room greetings, respect the resident's preferences and offer to read the daily activity flyer in the resident's room. Interview with Resident #20 on 03/17/25 at 9:08 A.M. stated the facility did not usually have activities on the weekends or evenings. Resident #20 stated they were bored on the weekends without activities. 2. Review of Resident #51's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia, schizoaffective disorder and essential hypertension. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 exhibited intact cognition. Review of the activity care plan dated 11/04/24 revealed Resident #51 was at risk for social isolation and low activity participation related to diagnosis of pneumonia and respiratory failure. Interventions dated 11/04/24 included interviewing resident about past roles, provide calendar of daily scheduled activities with times and locations, monitor for activity needs, invite/escort to activities of choice, room greetings, and respect resident preferences. Interview with Resident #51 on 03/17/25 at 8:52 A.M. stated the facility did not have activities on Saturday or Sunday. Resident #51 stated when there were no activities, they were bored. Review of the Activity Calendar from 01/01/25 to 01/31/25 revealed no activities were scheduled for Wednesday 01/01/25 (New Years Day). Only one weekend day, Sunday 01/05/25, had an activity scheduled that was not a movie (Saturday) or church service (Sunday) on the in-house TV channel. The facilities Activity Calendar from 02/01/25 to 02/28/25 revealed Saturday 02/15/25 and Sunday 02/16/25 had no activities scheduled. The other activities offered on Saturday or Sunday for the month of February included a movie on Saturdays on the facility in-house TV channel or a church service on Sundays on the facility in-house TV channel. The facilities Activities Calendar from 03/01/25 to 03/18/25 revealed four evening activities were scheduled. During the rest of the time-period, the latest scheduled activity was 3:45 P.M., which indicated a lack of evening activities. During review of the same dates, no activities were scheduled for Saturday 03/15/25. The Special Events schedule for 03/2025 revealed one evening activity and one weekend activity. Interview with Activities Director #849 on 03/19/25 at 2:56 P.M. stated normal evening activities were typically finished around 4:00 P.M. to 4:30 P.M. Activities on the weekend were normally movies and church service broadcasted on the in-house facility station which residents can watch in their rooms or in the living room area. Director #849 stated activity staff did not normally work on Saturday or Sunday and verified the activity calendars were correct. Review of the facilities Activity Policy revised 08/2006 revealed activity programs were designed to meet the needs of each resident which were available daily. Activities were scheduled seven days a week and residents were given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs.

Based on observation, medical record review, review of facility policy, and staff interview, the facility failed to ensure Resident #55's oxygen humidification was labeled and dated and Resident #68's oxygen tubing was changed and dated per facility policy. This affected two (Residents #55 and #68) of three residents reviewed for respiratory therapy. Findings include: 1. Review of Resident #55's medical record revealed the resident was admitted on [DATE] with diagnoses including heart failure, hypertensive heart disease with heart failure and depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 had moderate cognitive impairment. Review of Resident #55's respiratory care plan dated 01/25/23 revealed an intervention dated 05/08/23 to administer oxygen as ordered and keep head of bed elevated due to shortness of breath when lying flat. Review of Resident #55's physician orders revealed an order dated 05/25/23 for oxygen therapy per nasal cannula at two liters continuous to maintain a pulse oximetry above 90% every shift. Observation on 03/17/25 at 8:43 A.M. revealed a disposable oxygen humidifier (a medical device used to moisten supplemental oxygen) without an open date. Interview on 03/17/25 at 8:47 A.M. with Licensed Practical Nurse (LPN) #932 verified the disposable oxygen humidifier was missing an open date. Interview on 03/20/25 at 10:08 A.M. with LPN #916 confirmed if a resident did not have an order for humidification, the facility would have to determine who placed the oxygen humidification, would determine if the humidification was needed and obtain an order or remove the humidification as necessary. 2. Review of Resident #68's medical record revealed the resident was admitted on [DATE] with diagnoses including macular degeneration, dementia, and adult failure to thrive. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #68 seems or appears to have short term memory problems, long term memory problems, and severely impaired cognitive skills for daily decision making per staff assessment for mental status. Review of Resident #68's Respiratory Care plan dated 06/11/24 revealed an intervention to administer and monitor the effectiveness of oxygen therapy as ordered. Review of Resident #68's physician orders dated 06/13/24 revealed an order for humidification to the oxygen every shift; an order dated 05/30/24 for oxygen therapy per nasal cannula at two liters continuous to maintain pulse oximetry above 90% at bedtime and in the afternoon when napping. Observation on 03/17/25 at 8:00 A.M. revealed oxygen tubing labeled with a date of 01/02/25. The tubing labeled 01/02/25 was connected to the resident and in use at the time of observation. Interview on 03/17/25 at 8:05 with Licensed Practical Nurse (LPN) #932 verified the oxygen tubing was labeled 01/02/25. LPN #932 confirmed the oxygen tubing should be changed weekly by the oxygen company. Review of the facilities Oxygen Administration Policy and Procedure revised 08/16/24 revealed the oxygen servicing company would come on a weekly basis and change out tubing, masks and humidifiers. All tubing and masks must be changed weekly and stored in a bag at the resident's bedside. The policy stated to label the humidifier with the date and time opened and change the humidifier and tubing per the facility policy.

Based on record review and interview, the facility failed to ensure the physician was notified and responded timely to Resident #116's complaints of pain following a fall. This finding affected one (Resident #116) of three residents reviewed for falls. Findings include: Review of Resident #116's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, major depressive disorder and essential tremors. Review of Resident #116's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #116's fall Incident form dated 11/11/24 at 7:50 P.M. revealed Certified Nursing Assistant (CNA) #918 reported she saw the resident in the Centrum (main television lounge area) when she saw the resident stand up and attempt to walk. Before she could reach her, the resident had fallen on the floor and landed on her right side. The alarm was present in the wheelchair and alarming. CNA #918 stated she did not hit her head. Review of Resident #116's fall Investigation/Follow-Up form dated 11/12/24 at 9:27 A.M. authored by Licensed Practical Nurse (LPN) #956 revealed CNA #918 reported she was in the Centrum when she saw the resident stand up and attempt to walk. Before she could reach her, she had fallen on the floor and landed on her right side. The alarm was present in the wheelchair and was alarming. See the nursing notes regarding the fall. Continue to encourage the resident to be in the Centrum when up in a wheelchair. Continue with current interventions in place which include one-hour visual checks, chair tender and falling star program. Review of Resident #116's progress note dated 11/12/24 at 3:05 A.M. revealed the resident was resting in the Centrum and denied any needs or complaints of pain. Neurological checks were unremarkable, and range of motion (ROM) was as per normal. Staff would continue to monitor. Review of Resident #116's progress note dated 11/12/24 at 3:35 A.M. revealed the resident was assisted back to bed with the assist of two staff members and reported pain to the right hip/thigh area. The resident was able to move the leg with no swelling or bruising noted. A small bruise was noted below the knee. The resident did not rate the pain and the floor nurse to medicate the resident. The on-call service was contacted to ask for a X-ray and the answering service said to call the office in the morning. Review of Resident #116's progress note dated 11/12/24 at 8:49 A.M. revealed a call was placed to the physician to update on the resident's complaints of pain in the right hip and right leg area. New orders were received for an X-ray of the right hip, pelvic and right femur. Review of Resident #116's progress notes dated 11/12/24 at 8:52 A.M. revealed the resident's daughter was notified of the new orders and of complaints of right hip and right leg pain. Review of Resident #116's progress note dated 11/12/24 at 11:51 A.M. revealed at 11:30 A.M. the results of the X-ray was received and was noted with an acute subcapital hip fracture. A call was placed to the physician with orders to send the resident to the emergency department (ED). Interview on 01/14/25 at 10:30 A.M. with the Director of Nursing (DON) indicated the on 11/11/24, Resident #116 fell in the Centrum or common area and sustained a fracture at approximately 7:50 P.M. The DON stated the investigation revealed CNA #918 had observed the resident stand up and attempt to walk and subsequently fell on the floor on her right side. The DON confirmed the chair alarm was sounding, and the resident did not hit her head. He stated Resident #116 did not answer questions but was awake and alert. Interview 01/14/25 at 12:08 P.M. with Resident #116's daughter revealed concerns related to the resident being left in bed from the time of the fall until 12:30 P.M. the next day with a hip fracture. Telephone interview on 01/14/25 at 12:11 P.M. with CNA #918 revealed she was walking through the Centrum with a tray on 11/11/24 when she had observed Resident #116 trying to get out of her wheelchair. She stated she assisted the resident back into her wheelchair and then told her she would be with her in a second. She stated she felt the resident was settled back into her wheelchair, so she went to the food cart off the Centrum and placed a food tray on the cart. She stated as she turned, she heard Resident #116's chair alarm and the resident was almost on the floor. She stated it was a split second, and she did not see the actual fall but had observed as the resident fell to the floor. She stated she immediately went and got the nurse who was at the nursing station off the Centrum who then assessed the resident. CNA #918 indicated she did not observe any bruising or external rotation of Resident #116's legs and the resident did not complain of pain. She stated RN #856 assessed the resident and no injuries were noted so they helped the resident stand and placed her back into her wheelchair. CNA #918 revealed she took the resident to her room in the wheelchair and CNA #955 was going into the room to provide care to the resident. She was unaware of any other details. Interview on 01/14/25 at 12:40 P.M. with the DON indicated Resident #116 fell on [DATE] at 7:50 P.M., was assessed for injury and pain and nothing negative was identified. He stated on 11/12/24 at 8:49 A.M. the resident complained of pain and an X-ray was obtained which showed a left hip fracture. The DON confirmed Resident #116 was transferred to theER on [DATE] at 11:40 A.M. Telephone interview on 01/14/25 at 2:44 P.M. with Registered Nurse (RN) #856 revealed she was at the nursing station on 11/11/24 when she heard the CNA call out for assistance. RN #856 confirmed she had observed Resident #116 lying on her right side by the wheelchair. The CNA indicated the resident attempted to walk out of the wheelchair and had fallen on her right side. RN #856 revealed the resident denied pain, did not have external hip rotation, was able to move her hip and was able to get back into her wheelchair and be toileted. RN #856 denied Resident #116 had any injuries noted and she denied the resident had reported she hit her head at any point. She revealed Resident #116's neurological checks were negative. She stated she called the daughter to report the fall. She stated she went home around 11:00 P.M. and had to come back into the facility for dayshift on 11/12/24. She could not state the exact time she left and returned to the facility. RN #856 revealed when she returned on the morning shift on 11/12/24 she was told in report the resident had reported complaints of pain around 4:00 A.M. to 5:30 A.M. and an X-ray of her hip was obtained. She stated she had assessed Resident #116 early in the morning at an unknown time and the resident was sleeping. She stated she went back into the room a short while later and the resident complained of pain. RN #856 revealed Resident #116's X-ray results came back, and she called the physician with the results of the left hip fracture and obtained an order to send the resident to the emergency room . She stated she called the daughter to let her know of the new orders. Telephone interview on 01/15/25 at 1:54 P.M. with the Administrator in attendance of RN #865 (nightshift nurse on 01/12/24) revealed she had the called the on-call physician when Resident #116 complained of pain and they told her to call the physician back in the morning. She confirmed Resident #116 was sleeping once she was put in bed and medicated for pain. She denied concerns with the resident's care. Interview on 01/15/25 at 2:06 P.M. with the Administrator and the DON indicated the facility attempted to call Resident #116's physician and they on-call agency refused to put the nurse through to the physician. The Administrator stated she felt it was because the on call answering service was not willing to disrupt the physician at night. Interview on 01/15/25 at 2:14 P.M. with the DON indicated the staff would call him if it was a critical emergency and Resident #116 did not have any signs of a broken hip during the night on 01/12/24. He revealed if she would have had any signs such as a rotated hip or screaming in pain, then they would have immediately sent her out to the hospital. He stated the facility staff felt they had called the physician, was told to call back in the morning, the resident was stable and no immediate needs were not addressed. This deficiency represents non-compliance investigated under Complaint Number OH00160374.

Based on record review and interviews the facility failed to provide adequate and appropriate quality of care and services when transferring Resident #22 into bed after a fall incident. This affected one resident (Resident #22) of four residents reviewed for assistance with transfers. The facility census was 116. Findings include: Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia with behavior disorder, left shoulder pain, hyperlipidemia, aphasia, anxiety, major depressive disorder (MDD), and cognitive communication deficit. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/05/23, revealed the resident had severely impaired cognition. Resident #22 required extensive assist by one staff member for for bed mobility, wheelchair mobility, dressing, and eating and was totally dependent on two staff members for transfers, toileting, and personal hygiene. Review of the plan of care dated 09/10/20 revealed the resident was at risk for falls due to dementia, Alzheimer's disease, anxiety, MDD, and decreased mobility. Interventions included bed in lowest position, clutter free pathways, call light within reach, defined perimeter mattress (DPM) to bed at all times, body pillow to bed at all times, large touch pad with in reach, and a bed alarm to alert staff for safety. Review of physician orders for May 2023 identified orders for Resident #22's bed to be in the lowest position, clutter free pathways, call light with in reach, defined perimeter mattress (DPM) to bed at all times, body pillow to bed at all times, large touch pad with in reach, and a bed alarm to alert staff for safety. Review of the nurses notes dated 03/27/23 at 8:00 P.M. Licensed Piratical Nurse (LPN) #814 documented Resident #22 was found on the floor next to right side of bed. She documented injuries to residents mouth, bruising to right side of face and bruising with swelling to right hand including her second digit. The physician was contacted and gave orders to send resident to the local emergency room (ER) for evaluation and treatment. Resident #22's family was updated about the fall and new orders to send the resident to the ER. Nurse to nurse was called to the local ER. Review of nurses noted dated 03/27/23 at 11:32 P.M. Resident #22 returned from the ER with no new orders, all scans completed at the hospital including x-rays, and Computed Tomography scans revealed no fractures. Resident #22 had bruising to right side of face and to her right hand including her second digit. Review of the fall investigation dated 03/27/23 revealed all ordered fall interventions were in place, alarm was sounding when nurse entered room and found Resident #22 on the floor next to her bed. Staff witness statements revealed State tested Nursing Assistant (STNA) #804 and STNA #805 assisted Resident #22 to bed prior to her fall by using a two person transfer per her plan of care, then left the room together. LPN #814 entered Resident #22's room to give the resident her medicine and heard the alarm sounding and found the resident on the floor. LPN #814's statement included she ensured the resident was safe and did a quick assessment. LPN #814 noted bruising and swelling to resident right side of face, bleeding from her mouth and bruising and swelling to right hand including her second digit. LPN #814 yelled for help, found there was no one present in the hall way, so she ran to the nurses station to get help to assist the resident back to bed. Upon returning to Resident #22's room she found STNA #805 alone in the room with Resident #22, STNA #805 was standing next to the residents bed and Resident #22 was already in bed. LPN #814 questioned STNA #805 how the resident got back in bed and he stated he did not know, he found her in the bed with blood on her mouth. LPN #814 cleaned the residents face and notified the physician, the residents family, gave nurse to nurse to receiving hospital and obtained statements from all staff working at at the time of the fall. Interviews completed throughout the survey on 05/09/23 through 05/11/23 with the Administrator and Director of Nursing revealed on 03/28/23 via phone interview with STNA #805, STNA #805 told them he transferred Resident #22 off of the floor by himself even though he knew the resident was a two person transfer per her plan of care. He stated he lied the night before when she fell because he did not want to get in trouble for her falling. At the time of the phone interview STNA #805 was terminated due to his actions. Interview on 05/10/23 at 3:10 P.M. with LPN #814 verified she found Resident #22 on the floor next to her bed laying on her right side. LPN #814 noted bruising and swelling to right side of face, bleeding from her mouth, and bruising and swelling to her right hand including her second digit. LPN #814 yelled for help there was no one present in the hall way, so she ran to the nurses station to get help to assist the resident back to bed. Upon returning to Resident #22's room she found STNA #805 standing next to the residents bed. LPN #814 questioned STNA #805 how the resident got back in bed and he stated he did not know, he found her in the bed with blood on her mouth. LPN #814 cleaned the residents face and notified the physician, the residents family, gave nurse to nurse to receiving hospital and obtained statements from all staff working at time of the fall. This deficiency represents non-compliance investigated under Complaint Number OH000141625.

Based on medical record review, policy review and staff interview, the facility failed to ensure resident re-weights were obtained to verify accuracey of weight changes per facility policy. This affected one (Resident #101) of five residents reviewed for nutrition. The facility census was 114. Findings included: Review of Resident #101's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record including weight recording identified on 03/26/22 the resident's weight was 280.4 pounds. The next weight recorded on 04/14/22 was 286.8 pounds, a difference of 6.4 pounds from the prior weight. On 04/28/22 the weight recorded was 293.8 pounds, a difference of seven pounds from the prior weight. On 05/07/22 the weight recorded was 279.6 pounds, a difference of 14.2 pounds from the prior weight. On 05/14/22 the weight recorded was 286.6 pounds, a difference of seven pounds from the prior weight. On 05/21/22 the weight recorded was 284.6 pounds. On 07/02/22 the weight recorded was 274.6 pounds, a difference of 10 pounds from the prior weight. On 07/16/22 the weight recorded was 289.6 pounds, a difference of 15 pounds from the prior weight. On 07/30/22 the weight recorded was 273.6 pounds, a difference of 16 pounds from the prior weight. On 08/06/22 the weight recorded was 290.0 pounds, a difference of 16.4 pounds from the prior weight. On 08/13/22 the weight recorded was 264.8 pounds, a difference of 25.2 pounds from the prior weight. On 08/20/22 the weight recorded was 266.2 pounds. On 08/27/22 the weight recorded was 259.2 pounds, a difference of seven pounds from the prior weight. Review of the facility policy Weight Policy and Procedure with an updated date of 07/13/22 indicated if the weight had a five pound variance or more, either up or down, the nurse aide would be responsible to re-weigh the resident in 24 hours. Interview with the Director of Nursing on 08/31/22 at 1:10 P.M. verified staff did not obtained re-weights for Resident #101 to confirm accuracy of weights per the facility policy.

Based on medical record review and staff interview the facility failed to ensure hospice records including certification, assessments and visitation notes were available to the facility staff for collaborative care and services to Resident #101. This affected one (Resident #101) of two residents reviewed for hospice services. The facility census was 114. Findings included: Review of Resident #101's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record including paper medical chart in the nursing office found no evidence of any type of hospice certification paperwork, hospice assessments or hospice visitation notes. Interview with Unit Secretary #504 on 09/01/22 at 9:45 A.M. verified there was no evidence of any hospice certification paperwork, assessments and/or visitation notes in the resident's medical record or a separate binder located in the nursing office.

Based on record review, facility policy and procedure review and interview the facility failed to ensure all employees were checked against the Ohio Nurse Aide Registry (NAR) prior to or on their first day of work/hire to ensure the employee did not have a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This had the potential to affect all 114 residents residing in the facility. Findings include: Review of the personnel file for Registered Nurse (RN) #548 revealed a hire date of 03/28/22. There was no printed evidence of RN #548 being checked against the NAR prior to or on the first day of work/hire. Review of the personnel file for RN #547 revealed a hire date of 06/13/22. There was no printed evidence of RN #547 being checked against the NAR prior to or on the first day of work/hire. Review of the personnel file for Licensed Practical Nurse (LPN) #569 revealed a hire date of 07/05/22. There was no printed evidence of LPN #569 being checked against the NAR prior to or on the first day of work/hire. On 08/31/22 at 9:05 A.M. interview with Director of Nursing (DON) and RN #578 confirmed screening/checking employees through the Ohio Nurse Aide Registry for abuse, neglect, exploitation, and misappropriation were not completed for LPN #569, RN #547, and RN #548 prior to or on the first date of hire to ensure the employee did not have a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled Abuse and Neglect, revised 06/03/22, revealed the facility will not employ individuals who have a finding of abuse, neglect, or misappropriation of property in the State Nurse Aide Registry.

Based on interviews and record review, the facility failed to prevent Resident #1 from exiting the secured memory care unit (MCU) and sustaining minor injuries. This affected one resident (Resident #1) of three residents reviewed for elopement. The census of the MCU was 23. Findings include: Review of the medical record for Resident #1 revealed the resident was admitted on [DATE] with diagnoses including dementia without behavioral disturbance, Alzheimer's disease, age-related debility, and spinal stenosis. Review of physician orders revealed an order dated 01/27/21 for visual checks every hour, an order dated 06/16/21 for a wander-guard bracelet, and an order for 07/11/21 (after the elopement) for a personal motion alarm to Resident #1's doorway. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/02/21, revealed the resident was severely cognitively impaired, with occasional wandering, required limited assist of one for most Activities of Daily Living (ADL), used a walker for mobility and had no recent falls. Review of Resident #1's care plan of 08/11/20 revealed care areas for behaviors secondary to Alzheimer's Disease, as evidence by frequent wandering with exit seeking tendencies. Interventions included monitor behavior, intervene as necessary, try to identify cause, talking with resident in a calm reassuring and respectful manner, closely monitor doors and alarms, respond promptly and report any malfunctioning equipment. Review of Resident #1's progress notes and the incident report from 07/11/21 revealed Resident #1 was last seen by Licensed Practical Nurse (LPN) #200 on 07/11/21 at approximately 5:10 P.M. when she picked up his dinner tray. Resident #1 was found outside the exit door at the end of his hall at 5:20 P.M. by visitors driving down the private access road. Resident #1 was sitting in the grass approximately 20 feet from the building. The visitors drove Resident #1 to the main entrance of the adjacent assisted living where the charge nurse (Registered Nurse (RN) #250) was called and Resident #1 was returned to the MCU where he was assessed by RN #250. He was found to have an abrasion to his head and one to his mid-back. The physician and family were contacted. Neurological checks were initiated with no concerns noted. The resident was unable to explain how or why he went outside. Interview on 07/19/21 at 10:00 A.M. with Resident #1 revealed the resident pushed on the door and walked out. He was unable to report the reason for his exiting the facility or any further information. Interviews on 07/19/21 at 11:25 A.M. with Registered Nurse (RN) #251 and on 07/19/21 at 11:35 A.M. with LPN #200, revealed both staff were working on the MCU when Resident #1 eloped. Neither staff heard an alarm or were aware the resident exited the MCU until he was returned to the unit by RN #250. Interview on 07/19/21 at 12:09 P.M. with RN #250 revealed she received a call on 07/11/21 at approximately 5:25 P.M. from staff at the front desk of the adjacent assisted living informing her Resident #1 was brought to the front desk by visitors who found him sitting in the grass outside the memory care unit. She was unable to identify how the resident exited the secured unit without an alarm being heard by staff. She reported Resident #1 had abrasions to his head and mid-back and verified the three staff working the MCU should have heard an alarm, implemented the elopement protocol (Code Snoopy), and discovered Resident #1 was missing. Interview on 07/19/21 at 3:05 P.M. with the Administrator verified the facility was responsible for the safety of their residents and should have known when Resident #1 exited the MCU. Review of the undated Code Snoopy for missing residents revealed a process of notification and searching for a missing resident which was not implemented because the staff were not aware Resident #1 was missing. This deficiency substantiates Complaint Number OH 134.

Based on interview, record review, and review of a Self Reported Incident (SRI) the facility failed to ensure resident safety during transport. Actual Harm occurred on 01/29/21 when State tested Nurse Aide (STNA) #300 failed to apply a seat belt during transport and Resident #1 was thrown from his wheelchair when STNA #300 had to stop suddenly. This resulted in a fractured nose, bruises and skin tears to Resident #1. This affected one (Resident #1) of five residents interviewed for safety/falls. (Residents #1, #2, #3, #4 and #5). The facility census was 104. Findings include: Review of the medical record for the Resident #1 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. He was taking Eliquis, an anticoagulant which increased the risk of bleeding and bruising. Review of the Minimum Data Set (MDS) 3.0 dated 01/29/21 revealed the resident was cognitively intact, with no behaviors, required extensive assist of two for most Activities of Daily Living (ADL), used a wheelchair for mobility and had one fall with major injury (the incident on 01/29/21). Review of the care plan dated 01/29/21 revealed care areas for risk of falls, risk for impaired cardiovascular /pulmonary function related to hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of the progress notes from 01/29/21 revealed Resident #1 sustained a fractured nose, bruising to his head and skin tears on both arms as a result of being thrown from his wheelchair in the transport van. He was not wearing a seatbelt and slid out of his wheelchair and into a transport chair when STNA #300 stopped suddenly. He was treated at the emergency room and released later that day. Interviews on 02/08/21 at 9:00 A.M. with the Director of Nursing (DON) and the Administrator revealed Resident #1 was not wearing a seat belt while being transported on 01/29/21 by STNA #300 for a medical appointment. The resident's wheelchair was secured to the floor but the seat belt that wrapped over the wheelchair and attached to a mount on the floor was not in place. STNA #300 initially reported on 01/29/21 (the date of the accident) that Resident #1 was secured with a seatbelt when she had to brake suddenly to avoid a car that pulled out in front of the van. When questioned by the DON and the Administrator she admitted she did not secure the seatbelt around Resident #1 due to his size and her belief she would not be able to fasten it to the floor. STNA #300 was immediately suspended and later terminated on 02/03/21. Interview on 02/08/21 at 9:27 A.M. with Resident #1 revealed he was being transported by STNA #300, his wheelchair was secured, but he was not wearing a seatbelt. When STNA #300 had to stop suddenly, he flew out of his wheelchair hitting a transport chair that was fastened behind the driver's seat. STNA #300 drove him to the emergency room where he was treated for [REDACTED]. Observation on 02/08/21 at 11:35 A.M. of the transport van with the DON and Administrator revealed a transport chair was attached with a bungee cord to the backside of the driver's seat. Behind that was space for a wheelchair with hooks on the floor of the vehicle to secure each wheel. There was a long seatbelt mounted to the left of the space for the wheelchair which could be extended across the van and fastened to a knob protruding from the floor. The seatbelt appeared to be long enough that it could reasonably fit around a large resident and a wheelchair. Interview on 02/08/21 at 1:05 P.M. with STNA #300 revealed she did secure the wheelchair wheels to the floor but did not fasten a seatbelt around Resident #1 when she transported him on 01/29/21. She stated she did not think the seatbelt would reach due to his size. Review of the investigation for Self Reported Incident (SRI) dated 01/29/21 revealed STNA #300 was suspended pending investigation on 02/01/21 and terminated on 02/03/21. STNA #300 originally told Registered Nurse (RN) #200 on 01/29/21 Resident #1 was wearing a seatbelt, but was leaning forward when she had to stop suddenly, and he hit his head on the transport chair behind the driver's seat. On 02/01/21, STNA #300 admitted she did not place the seatbelt around the resident during transport due to his size and her belief the seatbelt would not stretch far enough to fasten it to the floor. The facility substantiated STNA #300's actions as neglect. This deficiency substantiates Complaint Number OH 857.

Based on record review and interview the facility failed to conduct quarterly Minimum Data Set (MDS) 3.0 assessments in a timely manner. This affected four residents (#9, #10, #13 and #15) of 14 residents whose medical records were reviewed for completion of assessments. Findings include: On 09/24/19 beginning at 4:30 P.M., Minimum Data Set (MDS) 3.0 assessment completion and submission information was reviewed with Registered Nurse (RN) Minimum Data Set (MDS) Coordinator #350. The following findings were noted regarding quarterly MDS 3.0 assessments: 1. Review of Resident #9's Assessment Lookup Information revealed a quarterly MDS 3.0 assessment was scheduled with an Assessment Reference Date (ARD) of 07/23/19. The log indicated the MDS was not completed. MDS Coordinator #350 verified Resident #9 had a quarterly MDS assessment with an ARD of 07/23/19 which had not been completed. 2. Review of Resident #10's Assessment Lookup information revealed a quarterly MDS 3.0 assessment was scheduled with an ARD of 07/29/19. The log indicated data entry had not been completed. MDS Coordinator #350 verified Resident #10 had a MDS with a ARD of 07/29/19 which was not completed. 3. Review of Resident #13's Assessment Lookup Information revealed a quarterly MDS 3.0 assessment was scheduled with an ARD of 07/31/19. The log indicated data entry had not been completed. MDS Coordinator #350 verified Resident #13's quarterly MDS with an ARD of 07/31/19 had not been completed. 4. Review of Resident #15's Assessment Lookup Information revealed a quarterly MDS 3.0 assessment with an ARD of 08/18/19 had not been completed. MDS Coordinator #350 verified Resident #15's quarterly MDS with an ARD of 08/18/19 was not completed.

Based on record review and interview the facility failed to ensure resident Minimum Data Set (MDS) 3.0 assessments were transmitted in the required time frames. This affected seven residents (#1, #2, #4, #5, #6, #7, and #8) of 14 residents reviewed for submission of assessments. Findings include: On 09/24/19 beginning at 4:30 P.M., submission of Minimum Data Set (MDS) 3.0 assessments were reviewed with Registered Nurse (RN) Minimum Data Set (MDS) Coordinator #350 with the following concerns identified regarding submission of assessment data: 1. Review of Assessment Lookup logs for Resident #1 indicated there was a quarterly MDS 3.0 assessment dated [DATE]. The log indicated data entry was completed 07/26/19 but the assessment had not been submitted. MDS Coordinator #350 verified Resident #1 had a MDS with an ARD of 07/05/19 which was completed 07/26/19 but had not been submitted. 2. Review of Assessment Lookup logs for Resident #2 indicated there was an annual MDS 3.0 assessment with an ARD of 07/06/19. The log indicated data entry was completed 08/02/19. The assessment had not been submitted. MDS Coordinator #350 verified Resident #2 had a MDS with an ARD of 07/06/19 which was not completed until 08/02/19 and which had not been submitted yet. 3. Review of Assessment Lookup logs for Resident #4 indicated there was a significant change MDS 3.0 assessment with an ARD of 07/03/19. The log indicated a data entry complete date of 08/02/19. The assessment had not been submitted. MDS Coordinator #350 verified Resident #4 had a MDS with an ARD of 07/03/19 which was marked as complete 08/02/19 but not submitted yet. 4. Review of Assessment Lookup logs for Resident #5 revealed there was a quarterly MDS 3.0 assessment with an ARD of 07/04/19. The log indicated a data entry date of 09/15/19. The assessment was not submitted until 09/20/19. MDS Coordinator #350 verified Resident #5 had a MDS with an ARD of 07/04/19 which was completed late (09/15/19) and submitted late (09/20/19). 5. Review of Assessment Lookup Information for Resident #6 revealed there was a comprehensive annual MDS 3.0 assessment with an ARD of 08/10/19. Data entry was completed 09/23/19 but had not been submitted. MDS Coordinator #350 verified Resident #6 had a MDS with an ARD of 08/10/19 which was marked as completed 09/23/19 but which had not been submitted yet. 6. Review of Assessment Lookup information for Resident #7 revealed there was a quarterly MDS 3.0 assessment dated [DATE]. The assessment was not submitted until 09/20/19. MDS Coordinator #350 verified Resident #7 had a MDS with an Assessment Reference Date of 07/05/19. The MDS was not completed until 09/13/19 and was not submitted until 9/20/19. 7. Review of Assessment Lookup information for Resident #8 revealed there was a quarterly MDS 3.0 assessment with an ARD of 07/10/19. The log indicated data entry was not completed until 09/22/19 and not been submitted. MDS Coordinator #350 verified Resident #8 had a MDS with a ARD of 07/10/19 which was not completed until 09/22/19 so it was done late and not yet submitted.

Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were completed as required. This affected three residents (#3, #11 and #12)of 14 residents whose medical records were reviewed for completion of assessments. Findings include: On [DATE] beginning at 4:30 P.M., Minimum Data Set (MDS) 3.0 assessment completion and submission information was reviewed with Registered Nurse (RN) Minimum Data Set (MDS) Coordinator #350. The following findings were noted related to the completion of annual MDS 3.0 assessments: 1. Review of Resident #3's Assessment Lookup Information revealed a comprehensive MDS 3.0 assessment was scheduled with an Assessment Reference Date (ARD) of [DATE]. The log indicated the MDS was not completed. MDS Coordinator #350 verified Resident #3 had an annual MDS assessment with a ARD of [DATE] which had not been completed. 2. Review of Resident #11's Assessment Lookup information revealed a comprehensive MDS 3.0 assessment was scheduled with an ARD of [DATE]. The log indicated data entry had not been completed. MDS Coordinator #350 verified Resident #11 had a MDS with a ARD of [DATE] which was not completed. 3. Review of Resident #12's Assessment Lookup Information revealed a comprehensive MDS 3.0 assessment was scheduled with an ARD of [DATE]. The log indicated data entry had not been completed. MDS Coordinator #350 revealed Resident #12 had expired on [DATE]. Resident #12 had an annual MDS assessment with a ARD date of [DATE] that had never been completed.

Based on record review and interview the facility failed to ensure quarterly quality assurance (QA) meetings were attended by a physician and the administrator, owner or board member. This had the potential to affect all 165 residents residing in the facility. Findings include: Review of quarterly sign in sheets for the QA meetings held in 10/11/18 and 01/10/19 revealed no evidence of physician attendance. The (MONTH) 2019 sign in sheet did not contain the signature of the administrator, owner or board member. On 09/26/19 at 6:05 P.M., QA nurse #360 verified the Administrator was a member of the QA committee but did not attend the quarterly meeting on 01/10/19. There was no physician attendance during quarterly QA meetings held 10/11/18 and 01/10/19.

Based on observation, interview and record review, the facility failed to ensure telephone access for Resident #90. This affected one of three residents reviewed for environmental concerns. Findings include: Resident #90 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of an annual Minimum Data Set assessment dated [DATE] revealed Resident #90 was unable to walk, had limited range of motion of both upper and lower extremities and required extensive assistance of two staff to transfer from the bed to a chair. Review of the Brief Interview for Mental Status (BIMS) dated 05/10/18 revealed Resident #90 was alert and oriented with no cognitive deficits. Review of the Resident Care Card dated 06/22/18 for Resident #90 read: Preferences: As desired, please make sure phone is within reach at all times so resident can make phone calls. An observation was completed on 07/24/18 at 9:00 A.M. Resident #90 was in bed, awake and watching television. A mobile overbed table was next to the left side of her bed. The table contained a few magazines and papers. The table was within her reach. A bedside table was on the left side of her bed, behind the mobile table. A small refrigerator, approximately three feet high, was on top of the bedside table. A sign on the door of the refrigerator read: Please make sure phone is by resident in case she needs to make a call. An older style telephone was observed on top of the refrigerator. The telephone was behind Resident #90 and far out of the resident's reach. An interview with Resident #90 was completed at the time of the observation. Resident #90 revealed the telephone was always out of reach. Resident #90 revealed she spoke with her daughter daily, but frequently missed the call and would have to call her daughter back. Resident #90 would then call the staff to put her telephone within reach. When the staff arrived, they would simply tell her, I forgot. Resident #90 added, I really let them have it if I miss a call from my family because I don't get to talk to them much. Resident #90 became tearful as she described missing her family. Resident #90 revealed she was the oldest of several siblings that lived out of the area and could only communicate by telephone. An observation was completed on 07/25/18 at 8:59 A.M. Resident #90 was awake and in bed. The telephone was on top of the refrigerator and out of her reach. An observation was completed on 07/25/18 at 2:15 P.M. with Registered Nurse (RN) Supervisor #605. Resident #90 was awake and resting in bed. The telephone was on the top of the bedside refrigerator, high and out of reach. Resident #90 verified she wanted her telephone within reach. RN #605 placed the telephone on the mobile bedside table, easily within reach. An interview was completed with RN #605 immediately following the observation. RN #605 verified the sign on the refrigerator was to remind the staff to keep the telephone within the resident's reach at all times. RN #605 verified the top of the refrigerator was out of the resident's reach.

Based on observation, interview and record review, the facility failed to ensure Resident #85 was free from prolonged periods of pain. Resident #85 exhibited and voiced repeated complaints of left upper arm pain which the facility failed to promptly respond to. This resulted in harm related to Resident #85 experiencing severe pain requiring 17 doses of a narcotic pain medication, for a period of eight days (from 07/20/13 until 07/28/13) prior to the resident being diagnosed with [REDACTED].#85) of four residents reviewed for accidents. The facility census was 177. Findings include: Resident #85 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #85 had severe cognitive impairment, experienced no pain, was unable to walk and required extensive assistance with activities of daily living. Review of an MDS 3.0 assessment dated [DATE] revealed Resident #85 had severe cognitive impairment, experienced daily pain, was unable to walk and required extensive assistance with activities of daily living. Resident #85 was observed on 09/04/13 at 5:02 P.M. The resident was observed sitting in a wheelchair in the main dining room. His wife was assisting him with the evening meal. Resident #85 had a sling on his left arm. Review of a nurse's note dated 07/20/13 at 12:10 A.M., revealed Resident #85 complained of left upper arm pain. The resident rated the pain an eight on the 0-10 scale, zero being no pain and 10, severe pain. Resident #85 was medicated with [MEDICATION NAME], a narcotic [MEDICATION NAME] at that time. The same nurse's note revealed no evidence the physician was notified of the complaint of pain. Review of a nurse's note dated 07/20/13 at 8:00 A.M., revealed Resident #85 complained of mild, left upper arm pain. Resident #85 grimaced with movement. A circular bruise was observed on the frontal aspect of the left axillary area. The same nurse's note revealed no evidence the physician was notified of the complaint of pain. Review of a nurse's note dated 07/20/13 at 6:00 P.M., revealed State tested nursing assistant (STNA) #3 reported to the nurse that Resident #85 complained of pain in the axillary area and the STNA noted a bruise. The nurse's note noted a red, circular shaped bruise to the axillary area. Resident #85 described pain in the left upper extremity as a four on the 0-10 scale. The same nurse's note revealed no evidence the physician was notified of the complaint of pain. Review of a nurse's note dated 07/21/13 at 12:15 P.M., revealed Resident #85 complained of left arm pain. A "large ecchymotic" area was observed in the resident's right axillary area. Resident #85 was medicated with [MEDICATION NAME]. The same nurse's note revealed no evidence the physician was notified of the complaint of pain. Review of a nurse's note dated 07/22/13 at 1:50 A.M., revealed Resident #85 complained of left arm pain. Resident #85 had decreased range of motion of the arm. At 10:43 A.M., the physician was notified of tenderness and bruising to the left axillary area. Review of a physician progress notes [REDACTED].#85 at 12:00 P.M. The progress note identified a healing contusion in the left axillary region and adequate range of motion. No new orders were written. Review of a nurse's note dated 07/22/13 at 4:30 P.M., revealed Resident #85 complained of left arm pain. Resident #85 described pain in the left upper extremity as an eight on the 0-10 scale. The same nurse's note revealed no evidence the physician was notified of the complaint of pain. Review of a nurse's note dated 07/23/13 at 6:15 P.M., revealed Resident #85 complained of "a little pain all over". Resident #85 described pain as a five on the 0-10 scale. The same nurse's note revealed no evidence the physician was notified of the complaint of pain. Review of a nurse's note dated 07/24/13 at 4:15 P.M., revealed Resident #85 complained of left upper arm pain. Resident #85 described pain in the left upper extremity as an eight on the 0-10 scale. The same nurse's note revealed no evidence the physician was notified of the complaint of pain. Review of a nurse's note dated 07/25/13 at 1:00 A.M., revealed Resident #85 was awake and complained of left upper arm and shoulder pain. Resident #85 described pain in the left upper extremity as an eight on the 0-10 scale. Resident #85 was medicated with [MEDICATION NAME]. The same nurse's note revealed no evidence the physician was notified of the complaint of pain. Review of a nurse's note dated 07/25/13 at 4:15 P.M., revealed Resident #85 complained of left upper arm. Resident #85 was medicated with [MEDICATION NAME]. The same nurse's note revealed no evidence the physician was notified of the complaint of pain. Review of a nurse's note dated 07/26/13 at 1:30 A.M., revealed Resident #85 was awake and complained of pain "all over". Resident #85 described the pain as an eight on the 0-10 scale. Resident #85 was medicated with [MEDICATION NAME]. The same nurse's note revealed no evidence the physician was notified of the complaint of pain. Review of a nurse's note dated 07/26/13 at 3:40 P.M., revealed Resident #85 complained of pain in the left arm. The same note revealed Resident #85 had been medicated with [MEDICATION NAME] at 2:45 P.M. Resident #85 described the current pain as an eight on the 0-10 scale. The nurse's note revealed no evidence the physician was notified of the continued complaint of pain after receiving [MEDICATION NAME]. Review of a nurse's note dated 07/27/13 at 4:15 P.M., revealed Resident #85 complained of pain "all over" at a mild level and pain in the left arm at a moderate level. Resident #85 refused to move the left arm. The same nurse's note revealed no evidence the physician was notified of the complaint of pain. Review of a nurse's note dated 07/28/13 at 1:10 A.M., revealed Resident #85 complained of severe pain to the left arm. The left arm and left hand were swollen. Resident #85 was medicated with [MEDICATION NAME]. The same nurse's note revealed no evidence the physician was notified of the complaint of pain. Review of a nurse's note dated 07/28/13 at 5:00 A.M., revealed Resident #85 was screaming out in pain to the left arm. The same nurse's note revealed no evidence the physician was notified of the complaint of pain. Review of a nurse's note dated 07/28/13 at 8:20 A.M., revealed the physician was notified the Resident's arm was pink, red and swollen. The resident described the left arm pain as "over 10" on the 0-10 pain scale. Resident #85 was transferred to the emergency room for evaluation. Review of an emergency room admission history and physical report dated 07/28/13 revealed Resident #85 "was found to have a left arm hematoma and left middle humerus (arm) fracture. An interview was completed with the assistant director of nursing, registered nurse (RN) #4, on 09/05/13 at 7:57 A.M. RN #4 said Resident #85 had a history of [REDACTED]. Review of a pain assessment, dated 07/15/13 revealed Resident #85 complained of pain "occasionally" and described the pain as "achy" and "sore". Resident #85 required no pain medication. Resident #85 rated the pain as a four on the 0-10 scale. Review of a pain assessment, dated 07/22/13 revealed Resident #85 complained of pain "frequently" and described the pain as located in the left arm as an "ache", "severe" and "stab". Resident #85 required [MEDICATION NAME], daily. Resident #85 rated the pain as a 10 on the 0-10 scale. Review of the Medication Administration Record [REDACTED]. The Tylenol was effective. Review of the MAR from 07/20/13 through 07/28/13 (the time period Resident #85 complained of arm pain), revealed Resident #85 received 17 doses of the narcotic medication, [MEDICATION NAME] for pain. During the interview completed with RN #4 on 09/05/13 at 7:57 A.M., RN #4 verified their was no evidence the physician was notified of the Resident's increasing pain and decreased range of motion after 07/22/13 until the resident was hosptalized on [DATE]. The RN also verified the lack of comprehensive assessment of the resident's pain, lack of investigation related to the cause or source of the pain and lack of timely treatment for [REDACTED].